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Journal of Biomechanics 38 (2005) 209214

A clinical overview patellofemoral joint and application to total knee arthroplasty

James B. Stiehl*
Columbia St Marys Hospital, 575 W.River Woods, Parkway #204, Milwaukee, Wisconsin 53212, USA

Abstract The mechanical function of the patellofemoral joint is an integral part of knee biomechanics, and remains a primary source of important clinical entities. Force transmission is the most central issue and can be described by relevant anatomical and biomechanical principles. The brief review highlights these issues focusing on recent applications to total knee arthroplasty. r 2004 Elsevier Ltd. All rights reserved.

1. Anatomical considerations The patella is a sesamoid bone that functions to guide the forces of the quadriceps muscles around the distal end of the femur (Hehne, 1990). The patellofemoral articulation is complex with shifting areas of contact throughout the range of motion. The femoral condyles have a dual articulation with the patella and tibial condyles adding to their complexity. Finally, the structures of the patellar tendon and extensor mechanism have a balanced origin and insertion and torque generation to perfect this articulation. With exion, the intercondylar surface of the distal femur slides under the patella for a distance of 57 cm. After this point, the articular surfaces of the femoral condyles diverge and have relatively small radii of curvature compared to the surfaces in the femoral intercondylar groove. The patella has medial ridge with a more curved surface than the medial facet which will articulate with the condyle. At 90 of exion, the upper part of the patella contacts the lower part of the femoral trochlea. After 120 , the patella lies only in contact with the femoral condyles. With this articulation, the medial facet articulation gives way to that of the medial ridge allowing for a more parallel articulation. The medial ridge actually moves more deeply into the intercondylar fossa and the patella translates laterally allowing for a height reduction of the medial patella (Powers et al.,
*Tel.: +1-414-961-6789; fax: +1-414-961-6788. E-mail address: jbstiehl@aol.com (J.B. Stiehl). 0021-9290/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbiomech.2004.02.026

1998). In contrast, the lateral patellar facet articulates directly on the lateral femoral condyle on its peripheral margin but the geometry of the lateral femoral condyle allows smooth tracking with a larger patellofemoral contact area in deep exion (Moro-oka et al., 2002). The transmission of forces depends on numerous factors, including the vectors of pull of the various quadriceps muscles which hold the patella centered in the intercondylar groove. For example, the vastus medialis has an origin more medially and dorsally which tends to hold the patella ush against the femur even in extension and to balance the lateral pull of the Q angle of the extensor mechanism. As noted above, the patella actually moves laterally with the articulation of the medial ridge, reducing the Q angle. Additionally, tibial internal rotation with knee exion causes this Q angle to disappear (Sanfridsson et al., 2001). If there is signicant weakness in the vastus medialis, the lateral subluxation of the patella will occur in early exion, leading to a signicant clinical entity (Sakai et al., 2000). The lateral retinaculum inserts onto the ventral surface of the lateral patella, which if imbalanced has important pathological consequences. With exion, the patella sinks into the intercondylar groove enhancing the pull of the lateral retinaculum and attached vastus muscles. Any vastus medialis imbalance results in both lateral displacement and increased lateral condylar contact pressure as the lateral condyle rises to resist this displacement. Another important mechanical phenomenon results when the knee exes to 90 . At this point, the extensor

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Fig. 1. Diagram demonstrates the different forces of the quadriceps: F1; and patellar tendon: F2; when the insertion of the quadriceps and origin of the patellar tendon are at different levels on the patella causing the R, the resulting pressing force which is the sum of F1 and F2; a1 is the lever arm of F1, a1+b=lever arm of F2 (From Hehne, 1990).

mechanism tends to pull the distal femur dorsally on the proximal tibia and is resisted by the collateral ligaments, joint capsule and the anterior cruciate ligament. However, the vastus muscles change their vector of pull and become knee exors similar to the hamstring tendons. This force which is exerted through the patella retinaculum causes the proximal tibia to translate dorsally as well and has been characterized as the tibial shear force. The points of insertion of the patella tendon and quadriceps tendon are at different levels in the sagital plane of the patella (Fig. 1). For the quadriceps tendon, it attaches to the patella closer to the joint surface than the patellar tendon. The levering effect of the patellar tendon implies that the force transferred through this tendon is signicantly less than the quadriceps mechanism. The other issue is the transfer of force of the quadriceps mechanism to the distal femur beginning at 70 of exion. This tends to limit any increase in retropatellar pressure after 70 of exion as these forces are now taken up by the quadriceps mechanism (Heegaard et al., 1995).

this length moves patellofemoral contact inferior causing a greater moment arm and enhancing the levering of the quadriceps tendon. In result, there is a higher patellar force concentration and a greater transmission to the patella ligament. At 82 of exion in normal knees, the quadriceps tendon wraps around the distal femur, which rapidly reduces the amount of force transmitted through the patella and patella tendon (Yamaguchi and Zajac, 1989). The extensor moment generated across the patellofemoral joint is multifactorial being related to tibiofemoral contact, the quadriceps/patellar tendon force ratio and the patellar tendon angle. Draganich et al. have found that the largest extension moment of the patellofemoral joint occurs at 1530 of knee exion (Fig. 2). This rapid increase in tension results from the posterior movement of the location of the femoraltibial contact increasing the patellofemoral lever arm. Furthermore, the direction of pull of the patellar tendon which is anterior at full extension, moves signicantly posterior from 2090 of exion. Again the posterior direction of pull on the patellar tendon results in the posteriorly directed tibial shear force which resists any quadriceps-to-patellar tendon force to pull the proximal tibia ventrally or anterior (Ahmed et al., 1987; Draganich et al. 1987; Huberti et al., 1984). Komistek et al. have evaluated lower extremity joint reaction forces using Kanes method of dynamics (Komistek et al., 1998a, b) Fig. 3. This approach uses known variables such as ground reaction forces, gravitational forces, inertional forces of the lower extremity and relative joint motions determined form gait lab and uoroscopic measurements. From a threedimensional model of the lower extremity, joint velocities and angular joint velocities were used to solve differential equations which output the joint reaction forces under various load bearing conditions. For the

2. Biomechanical considerations Numerous biomechanical studies have analyzed the patellofemoral joint and have suggested an important levering function as opposed to a simple pulley spacer (Ahmed et al., 1987; Andriacchi et al., 1996; Draganich et al., 1987; Hehne, 1990). Factors related to patella kinematics are the comparison of the femorotibial and patellofemoral contact and the angular orientation of the patella and the patella ligament. With increasing exion, the effective moment arm decreases because the patella ligament swings posterior as the patella falls into the median femoral groove, reducing the actual moment arm. Also the patellofemoral contact migrates superior decreasing the mechanical force advantage of the patella lever. Patella tendon length is important as increasing

Fig. 2. For a given quadriceps force, the extension torque peaks at 25 of exion based on the femorotibial contact position, quadriceps-topatella force transfer, the changing angle of the patellar ligament (from Draganich et al., 1987).

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Fig. 3. Joint reaction forces of the hip, knee, ankle, and patella during normal gait (from Komistek et al., 1998a, b).

Fig. 4. Sulcus of the intercondylar femoral groove form a sulcus angle which is located about 4 lateral to the mechanical axis and 2 medial to the femoral anatomical axis.(from Eckhoff et al., 1996).

patellofemoral joint this measurement was on the order of 0.20.4 times body weight during normal walking. It is believed this calculation is representative as similar solutions for the hip joint in the same model closely approximates results from telemetric measurements. Future efforts are needed to assess other functional activities and those situations of prosthetic substitution.

3. Patellofemoral kinematics in total knee arthroplasty For total knee arthroplasty, an important anatomical consideration is tracking of the patellofemoral joint. As distal femoral trochlear anatomy is quite variable, various parameters of this anatomy must be underdstood. From prior anatomical studies, it has been shown that the patellofemoral groove approximates a circular arc with a mean radius of 22 and the distal femoral sulcus forms an arc of 117 . The position of the patellar groove in relation to the mechanical axis which is the line from the center of the femoral head to the femoral intercondylar groove in the coronal plane was on average 1.4 medial but the range was from 7 lateral to 7 medial. When comparing the relationship of the patellar groove to a perpendicular drawn to the posterior femoral condylar axis, the groove angled laterally about 3 .(Feinstein, et.al. 1996). Similiarly, another study dened the patellar groove as a sulcus axis the angled laterally about 4 in relation to the transepicondylar axis.(Fig. 4) (Eckhoff et.al., 1996). The effect of total knee arthroplasty on the anatomical position of the femoral groove has been a topic of investigation. Clearly a number of mechanical factors have existed in earlier designs which caused signicant patello-femoral complication rates such non-anatomic restoration of the sagital position of the patellar groove, internal rotation of the femoral or tibial component in

relation to the transepicondylar axis, and the symmetrical shapes of the patellar groove that does not accommodate the rather large variability of the patellar groove angle. One cadaver study demonstrated that the patellar displaced 4 and 4 millimeters medially between 0 and 120 after posterior cruciate retaining total knee arthroplasties, effectively increasing the Q-angle and the lateral shearing forces on the patella.(Rhoades et.al., 1990) An important clinical study evaluated a group of patients who had suffered patellofemoral complications after total knee arthroplasty nding that small amounts of femoral and tibial component internal rotation caused lateral patellar tracking and tilting, while larger amounts caused subluxation or frank dislocation.(Berger et.al., 1998; Andriacchi, 1993). The normal biomechanics of the knee joint can be signicantly altered in total knee arthroplasty by substantial changes to the normal anatomical relationships (Andriacchi et al., 1982, 1987). In general, the most substantial alterations occur resulting from removal of one or both cruciate ligaments and from the prosthetic shape of the femoral component that fails to recreate the normal spatial relationships of the patellofemoral joint with the expected kinematic function. Removing the cruciate ligaments causes a joint line elevation which has been shown to reduce exion moments and disrupt the normal femoral tibial contact or femoral rollback seen with knee exion. Both of these changes diminish the normal levering effect of the patellofemoral joint. Specically for the patellofemoral joint, moving the patellofemoral joint contact superiorly with joint line elevation reduces the mechanical advantage of the patellar lever. This cannot be improved by increasing the thickness of the patella, as the force transfer of the extensor mechanism moves to the quadriceps tendon after 35 of exion. Thus, at high degrees of exion, patella thickness has minimal effect.

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Finally, the effect of prosthetic design on these various problems is very poorly understood. Sufce it to say that no known total knee prosthesis to date has restored the normal extension function of the patellofemoral joint. In total knee arthroplasty, in vitro studies have evaluated sagital plane patellofemoral contact area in normal and total knee arthroplasty. Huberti and Hayes evaluated 12 human cadaver knees nding distal patellofemoral contact at 20 exion and proximal migration to the most proximal portion of the patella at 120 exion (Huberti and Hayes, 1984). Takeuchi et al. studied patellofemoral contact in cadavers with six total knee types nding an inconsistent superior or inferior shift of the contact area with exion (Takeuchi et al., 1995). Stiehl et al. used dynamic video uoroscopy under weight bearing conditions to investigate sagital plane patellofemoral kinematics in total knee arthroplasty (Stiehl et al., 1995). Patellar ligament rotation, which measures the angle formed by the patellar tendon and the longitudinal axis of the tibia started at 16 extension in normal knees and progressed to 0 . Prosthetic knees had a decreased angle in extension, which also progressed to 0 with exion. Patella axis rotation, which compared the angle between the patellar tendon and the sagital axis of the patella, increased with knee exion in both normal and total knees, but was greater than normal in total knees in full exion. Two abnormalities rst identied in that study included abnormal patellar separation in full extension and a pie-shaped or wedge gap opening at the distal pole of the patella as the patellar prosthesis articulated on the more superior surface of the dome shaped patellar prothesis. Stiehl et al. previously investigated the LCS mobile bearing anatomical patella comparing the results with or without posterior cruciate ligament sacrice (Stiehl et al., 1997, 2000). Patellofemoral contacts of both mobile bearing implants were similar to normal but tended to be more inferior with higher degrees of exion which contrasted with the superior position seen on dome shaped implants. Patella ligament rotation was lower than normal in the mobile bearing implants reecting the posterior femorotibial contact in extension and anterior translation beyond 60 exion. Patellar axis rotation angles were similar for normal and total knees. Stiehl et al. used in vivo video uoroscopy to investigate patellofemoral kinematics of multiple possibilities comparing the position of patellofemoral contact, patellar tilt angle which measured the change of the axis of the patella in relation to the long axis of the tibia, and separation of the patellofemoral joint in extension (Stiehl et al., 2001). (Figs. 5). This was compared with normal, anterior cruciate decient knee, xed bearing posterior cruciate retaining total knees with a dome patella, xed bearing posterior stabilized total knees with a dome, and the mobile bearing rotating platform

Fig. 5. Patellar Tilt Angles from extension to 90 exion with various conditions (from Stiehl et al., 2001).

LCS, with and without patellar resurfacing. In that study, patellofemoral contact position moved superior in normal and ACLD knees in virtually identical fashion. All TKA experienced a more superior contact position at full extension through 30o of knee exion, and this pattern continued for subjects having a xed bearing PCR or PS TKA at 60 and 90o of knee exion. However, the mobile bearing resurfaced and unresurfaced patellae with the posterior cruciate sacricing LCS implant had contact positions similar to normal knees at 60 and 90 exion. For the entire group the most superior overall patellofemoral contact pattern was determined for subjects having a posterior cruciate retaining total knee. The authors attributed this nding to a variety of issues including the loss of normal rollback with many posterior cruciate retaining total knees, subtle joint line elevation, and certain anatomical issues that may be related to surgical technique. The patellar tilt angles of the domed patellae were similar with posterior cruciate retention or substitution and were greater than normal or ACLD knees. Again, this may reect joint line elevation with posterior cruciate sacrice or abnormal posterior femorotibial contact positioning seen with posterior cruciate retaining knees. The patellar tilt angles of unresurfaced mobile bearing TKA were most similar to normal knees. Subjects having a resurfaced MB TKA experienced larger patellar tilt angles compared with subjects having a MB unresurfaced TKA, but were lower than those values determined for xed bearing TKA having domeshaped patellae. This may reect the relative anatomical shape of the mobile bearing patella. The authors concluded that patellar tilt angles produced trends comparable to patellofemoral contact analysis with higher patellar tilt angles correlating with more superior patellofemoral contact. They did not investigate joint line elevation or possible changes of patellar tendon length in their study. The most abnormal kinematics occurred with the dome shaped patella after posterior

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cruciate retention. Factors noted were the more superior location of patellofemoral articulation and the anterior femoraltibial articulation which may cause the tilting noted in these cases. Again, the author emphasizes that the most normal circumstance occurred with the unresurfaced patella after total knee arthroplasty, supporting the kinematic function of this approach. Recent study to measure the contact pressures of native patellas after TKA have shown that in over 80% of the contact area, the stresses are lower than the yield strength of articular cartilage (Bennjamin et al., 1998). Also, long-term studies of unresurfaced patella after total knee arthroplasty suggest that a desirable femoral trochlear design may be the most crucial factor (Kulkarni et al., 2001; Keblish et al., 1994). Patellofemoral separation in extension was seen in several kinematic studies and may be explained in part by femorotibial contact, which tends to be more posterior for total knees and some ACLD knees (Komistek et al., 1998a, b, 2000; Stiehl et al., 2001). The highest incidence and magnitude of separation was seen in total knees with posterior cruciate retention, which may reect absence of the anterior cruciate ligament and posterior femorotibial contact in extension. Posterior cruciate substituting total knees also demonstrated a substantial number with this nding but only half the number seen with posterior cruciate retention. Dennis et al. has shown that femorotibial contact with PS TKA will, on average, be more anterior than PCR TKA, which could explain this difference (Dennis et al., 1996). Interestingly, in Stiehls study, none of the unresurfaced or resurfaced anatomical MB TKA demonstrated separation, and were comparable to normal knees. The clinical implication of patellofemoral separation is unknown but could explain certain clunks that some patients experience. Miller et al. used a cadaver method to recreate patellofemoral forces with various prosthetic implant techniques (Miller et al., 2001). They found that with a medial unicompartment arthroplasty with a meniscal bearing prosthesis where both cruciate ligaments were preserved, the patellofemoral forces were not different from the normal knee. With total knee arthroplasty and posterior cruciate retention, the patellar forces were signicantly lower than the intact knee at 20 and 40 of exion and signicantly higher at 100 and 120 of exion. For the posterior stabilized arthroplasty with incision of both cruciate ligaments, patellar forces were diminished at 20 of exion but were comparable to normal at higher degrees of exion. They assessed the patellar tendon angle which measures the angle of the shaft of the tibia with the patellar tendon and found changes which could impart could explain alterations of the patellar levering mechanism. The unicondylar arthroplasties remained comparable to normal knees throughout range of motion but in the posterior cruciate

retaining arthroplasties, in 20 and 40 of exion, the angles were less while in 100 and 120 of exion, they greater than normal. This could be explained by the well recognized sagital plane kinematic abnormalities of the posterior cruciate retaining total knees which are posterior in extension and move anteriorly in deep exion. For the posterior stabilized implants, the patellar tendon angle was less than normal at 20 , 40 and 60 of exion, but normal at higher degrees of exion. Again, this may reect a posterior femoraltibial contact in near extension.

4. Discussion From this brief review of the literature, much is known about the function of the patellofemoral joint. However, controversy still persists about various orthopaedic treatments of anterior knee pain, which is a common ofce complaint. Two of the most effective operations are lateral retinacular release of the patella and anteromedialization of the proximal tibia (Molina et al., 1995). In the eld of reconstructive surgery, total knee arthroplasty is one of the most commonly applied surgical methods. Yet, the existing surgical techniques in each of these areas probably do not restore the function of the knee to normal as recorded by gait analysis or other functional criteria. Also, we are beginning to understand that certain demographic may be important and predictive. For example, a recent study indicated that patellar contact areas are less in women causing pressures generated by varying vastus medialis pull to be more sensitive (Csintalan et al., 2002). The parameters of rehabilitation also are poorly understood. For example, how much muscle performance of the vastus medialis is needed to correctly balance the patellofemoral articulation and can this function be measured and assessed over a period of time (Lee et al., 2002). The biomechanical analysis of the patellofemoral joint will require more sophisticated investigations in the future. In vitro cadaveric models are helpful at least with parametric studies to demonstrate obvious trends. However, we must understand the forces of articular surface loading and how these become altered in disease states and with mechanical alterations from trauma, abnormal development, or prosthetic replacement. In the future, computerized modeling will be needed to generate solutions to these complex problems. Only then can we plan appropriate surgical procedures that will guarantee effective outcome in most cases.

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